Failure to Implement and Follow Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, for multiple residents reviewed for abuse policies. Specifically, the facility did not report incidents of resident-to-resident abuse within the required 2-hour timeframe, as outlined in their own policy. Several incidents were not reported to the state agency until days after they occurred, and in some cases, were not reported at all. Additionally, the facility did not gather required written statements for these incidents, nor did they complete the State Provider Investigation Report (5-day report) as mandated by their policy. The report details several incidents involving residents with significant cognitive impairments and behavioral health diagnoses, such as Alzheimer's disease, dementia, bipolar disorder, and psychotic disorders. In one instance, a resident was hit in the back by another resident, and in another, a resident was punched in the face, resulting in a non-displaced nose fracture. There were also incidents where residents were scratched, pushed, or otherwise physically harmed by other residents, leading to injuries such as skin tears and a vertebral compression fracture. Despite these events, the facility failed to follow its own procedures for documentation, investigation, and timely reporting. Interviews with staff and administration revealed a lack of understanding and adherence to the facility's abuse reporting policy. The Administrator was unaware of the 2-hour reporting requirement and did not know about the necessary forms and investigation timelines. Other staff members described notifying supervisors but did not consistently follow through with required documentation or reporting. The facility also failed to analyze these occurrences to determine if changes to policies and procedures were needed and did not refer all incidents to the QAPI committee for further review, as required by their own policy.
Removal Plan
- Residents had interventions put in place including separation from other residents when resident to resident altercations occurred.
- Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient.
- Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behavior were noted.
- Resident #2 & Resident #1 were separated from one another and both sent to ER, while in ER staff made referral to inpatient behavioral hospital. Both Residents #2 & #1 were admitted to inpatient behavioral hospital.
- Abuse reportable events policy was reviewed and revised to include steps for reporting, documentation required and time to report events.
- Abuse/neglect in-services were started with all staff by the Administrator, the DON, nurse managers and department supervisors; all employees must be educated before working their scheduled shift.
- Social Services in-serviced Administrator to complete safety surveys with each incident, especially any allegations of abuse/neglect, to ensure residents feel safe in the facility and they have not experienced any negative events.
- The DON and Nurse manager assigned to educate nurses on documentation related to incidents, including incident reports, witness statements, progress notes, monitoring logs and head to toe skin assessments.
- Per facility policy, charge nurse will be the staff member that begins taking written statements after the allegation is reported to the Administrator and DON.
- Safety surveys started by department heads for residents that could answer survey questions; secured unit charge nurse contacting family members for residents on the secured unit with impaired cognition.
- Resident council meeting scheduled for residents to discuss revision to policy including the steps to reporting and the required documentation that was needed for completing an investigation related to an incident that occurred and was a reportable event.
- Department heads would speak to residents individually that did not attend the meeting and call family members with residents that have impaired cognition. The Administrator would be completing the meeting with residents.
- The Regional director of operations in-serviced the DON and Administrator on revision to policy on abuse/neglect allegations. Policy now has specific contact information with multiple methods of notification including email, phone, and TULIP. Multiple methods on how to submit 3613 investigation report including email, TULIP, and fax.
- Regional Director of operations visited the facility on a monthly basis and would follow up with the Administrator/DON with each self-report to ensure the investigation of self-reports were completed in timely manner and 3613 was submitted to state with all the documentation gathered with investigation. All communication between monthly visits were to be sent through email.
- The Nurse manager started in-service with nurses to discuss documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in-services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that was required for investigation. In-service was related to having more thorough assessment and appropriate documentation in place. In-services would be completed before staff worked the next shift.
- The facility's Abuse Reportable events Policy was reviewed and revised to clarify timelines for internal/external reporting and investigation steps. The revised policy was approved by the Governing Body and redistributed to all departments.
- Future new hires will receive abuse prevention and reporting training during orientation before working any shift.
- The DON or designee will initiate and complete all abuse investigations using the state-approved Form 3613-A process.
- All investigations will be reviewed and signed by the Administrator for accuracy and timeliness before submission.
- The Administrator or DON will audit all incident reports weekly to ensure proper reporting, investigation, and documentation.
- Results will be presented to the QA Committee monthly for review and any needed corrective actions.
- The QA Committee will evaluate compliance and determine if further education or policy revisions are needed.